Top 5 most challenging requirements for 2021

Rank

Standard

Element of performance

Ambulatory Health Care

1

IC.02.02.01: The organization reduces the risk of infections associated with medical equipment, devices, and supplies.

EP 2

2

IC.02.01.01: The organization implements infection prevention and control activities.

EP 2

3

MM.01.01.03: The organization safely manages high-alert and hazardous medications.

EP 2

4

EC.02.05.01: The organization manages risks associated with its utility systems.

EP 7

5

MM.01.02.01: The organization addresses the safe use of look-alike/sound-alike medication.

EP2

5

HRM.01.02.01: The organization verifies and evaluates staff credentials.

EP 1

Behavioral Health Care and Human Services

1

NPSG.15.01.01: Reduce the risk for suicide.

EP 2

2

NPSG.15.01.01: Reduce the risk for suicide.

EP 1

3

NPSG.15.01.01: Reduce the risk for suicide.

EP 5

4

NPSG.15.01.01: Reduce the risk for suicide.

EP 3

5

NPSG.15.01.01: Reduce the risk for suicide.

EP 4

Critical Access Hospitals

1

IC.02.02.01: The critical access hospital reduces the risk of infections associated with medical equipment, devices, and supplies.

EP 2

2

NPSG.15.01.01: Reduce the risk for suicide.

EP 5

3

EC.02.05.01: The critical access hospital manages risks associated with its utility systems.

EP 15

4

EC.02.02.01: The critical access hospital manages risks related to hazardous materials and waste.

EP 5

5

MM.06.01.01: The critical access hospital safely administers medications.

EP 3

Home Care

1

IC.02.01.01: The organization implements the infection prevention and control activities it has planned.

EP 2

2

RC.02.01.01: The patient record

contains information that reflects the patient’s care, treatment, or services.

EP 2

3

PC.01.03.01: The organization plans the patient’s care.

EP 10

4

NPSG.15.02.01: Identify risks associated with home oxygen therapy such as home fires.

EP 1

5

LD.01.03.01: Governance is ultimately accountable for the safety and quality of care, treatment, or services.

EP 12

Hospitals

1

IC.02.02.01: The hospital reduces the risk of infections associated with medical equipment, devices, and supplies.

EP 2

2

NPSG.15.01.01: Reduce the risk for suicide.

EP 1

3

MM.06.01.01: The hospital safely administers medications.

EP 3

4

EC.02.06.01: The hospital establishes and maintains a safe, functional environment.

EP 1

5

EC.02.05.01: The hospital manages risks associated with its utility systems.

EP 15

Laboratory and Point-of-Care Testing

1

QSA.01.02.01: The laboratory maintains records of its participation in a proficiency testing program.

EP 2

2

QSA.02.08.01: The laboratory performs correlations to evaluate the results of the same test performed with different methodologies or instruments or at different locations.

EP 2

3

HR.01.06.01: Staff are competent to perform their responsibilities.

EP 18

4

QSA.02.11.01: The laboratory conducts surveillance of patient results and related records as part of its quality control program.

EP 7

5

NPSG.02.03.01: Report critical results of tests and diagnostic procedures on a timely basis.

EP 2

Nursing Care Centers

1

EC.02.02.01: The organization manages risks related to hazardous materials and waste.

EP 5

2

HR.02.01.04: The organization permits licensed independent practitioners to provide care, treatment, and services.

EP 1

3

HR.02.01.04: The organization permits licensed independent practitioners to provide care, treatment, and services.

EP 5

4

IC.02.01.01: The organization implements its infection prevention and control plan.

EP 1

5

WT.03.01.01: Staff and licensed independent practitioners performing waived tests are competent.

EP 5

Office-Based Surgery

1

IC.02.02.01: The practice reduces the risk of infections associated with medical equipment, devices, and supplies.

EP 2

2

IC.02.01.01: The practice implements infection prevention and control plan.

EP 2

3

MM.01.01.03: The practice safely manages high-alert and hazardous medications.

EP 2

4

EC.02.04.03: The practice inspects, tests, and maintains medical equipment.

EP 4

4

HR.02.01.03: The practice grants initial, renewed, or revised clinical privileges to individuals who are permitted by law and the organization to practice independently.

EP 5